This guide acts as a roadmap on how to apply for (and win) disability benefits when you become unable to work due to fibromyalgia. We review the available disability benefits for fibromyalgia, how to apply for these benefits, how to maintain these benefits once you are approved, as well as how to appeal if you are denied. We then end by discussing the key problems you must overcome to win disability benefits for fibromyalgia. This Guide is part of our Beginner's Guide Series on winning disability benefits for medical conditions.
We will cover the following topics:
- The role of doubt and suspicion in disability claims for fibromyalgia
- Transitioning from work to sick leave for fibromyalgia
- Types of disability benefits available for fibromyalgia
- How to apply for disability benefits for fibromyalgia
- Maintaining disability payments once your claim is approved
- How to appeal a disability claim denial for fibromyalgia
- Unique challenges of winning long-term disability benefits for fibromyalgia
- Case studies
- Final thoughts
1.The Role of doubt and suspicion in disability claims for fibromyalgia
According to the Arthritis Society, approximately 700,000 Canadians live with fibromyalgia. It most commonly affects people who are over 40 years old and the risk of having it increases with age. While fibromyalgia was once considered a disease of the muscle tissue, it is now understood to be caused by impairment of the body's pain processing mechanisms. Fibromyalgia is a form of chronic widespread pain.
While the symptoms of fibromyalgia can be disabling, there are no definitive medical tests that can verify the severity of the condition. Doctors diagnose fibromyalgia based on a physical exam combined with subjective verbal complaints from the patient being examined; these characteristics of fibromyalgia make it an invisible illness. In a society where seeing is believing, the main issue with fibromyalgia is that others aren’t able to see the illness on paper, so they will doubt the severity of your condition.
Living with fibromyalgia is a constant struggle: the pain, headaches, anxiety and depression, and fatigue all takes a toll on you both physically and emotionally. Like most people, you have struggled for months or even years before getting to the point where you can no longer work. With financial pressures mounting, the most difficult thing is when people doubt the seriousness of what you are going through. Family members, co-workers and health care providers are often supportive in the beginning, but over time as your symptoms become chronic, you can feel the doubt creeping in; they may not come right out and say it, but you can feel it still. They may assume that you are exaggerating, or you are just lazy, they could think you are trying to get out of doing the hard jobs at work, or you are simply looking for attention, when nothing could be farther from the truth. Every client we have worked with has experienced this to some degree.
Unfortunately, when you apply for disability benefits, the problem of others doubting you can become much worse. The disability benefit providers — insurance companies and government programs — are suspicious of people claiming disability caused by invisible illnesses. They can’t see fibromyalgia on an x-ray or in lab results, so they assume you are making it up or exaggerating your symptoms. The doubts you have experienced with others multiply a hundred times when dealing with disability benefit providers. Disability claims based on invisible illnesses are the most difficult to win, you need to approach the disability claim process differently. If you are not careful, your actions will only reinforce the insurance company's disbelief in the seriousness of your symptoms. You need to anchor your case with a compelling story that will overcome the natural instinct of others to disbelieve you.
2.TRANSITIONING FROM WORK TO SICK LEAVE FOR FIBROMYALGIA
You must carefully plan your transition from work to being on sick leave. A fibromyalgia diagnosis does not result in an automatic approval of long-term disability benefits. This is because the disability caused by fibromyalgia can vary widely from person to person. Some people with fibromyalgia can work, while others are totally disabled. You must plan ahead so you will have documents to show how your situation is different from others who have fibromyalgia but are still able to work. Failing to plan for the transition from work to sick leave can be an absolute disaster. If you don't act carefully, you could get fired, not have the support of your doctor, lose your disability benefits and reinforce the insurance company's negative beliefs about you.
3.Types of disability benefits available for fibromyalgia
Not everyone who has fibromyalgia will qualify for disability benefits. You will not qualify for disability benefits just because you have a new diagnosis of fibromyalgia. Rather, you will only qualify for disability benefits if the symptoms and impairment from fibromyalgia cause you to be unable to work on a regular basis. Even if you have disabling symptoms, you need to be eligible to apply for disability benefits under a given disability plan or insurance policy. Eligibility is based on you being a recent worker who paid into the program in question.
Following are the most common disability benefits plans and programs available for someone unable to work because of fibromyalgia:
- Employment Insurance (EI) sickness benefits
- Short-term disability insurance benefits
- Long-term disability insurance benefits
- CPP disability benefits
3.1 EI Sickness Benefits
EI sickness benefits are a type of temporary disability benefit paid through the employment insurance program. To be eligible for benefits, you must be a recent worker who made the minimum recent contributions to the EI program. You must also have exhausted all sick pay from work and not be receiving short-term disability insurance benefits. You must also have a medical certificate from your doctor confirming you are unable to work due to illness. EI sickness benefits pay 55% of your pre-disability weekly salary and pay for a maximum of 15 weeks.
Learn more by visiting our article on the EI Sickness Benefits Program.
3.2 Short-term Disability Benefits
Short-term disability benefits are disability benefits are paid by your employer (through a workplace disability plan) or by an insurance company (through an insurance policy). If you have group benefits as part of your employment, it is possible they include disability benefits. Short-term disability benefits are typically paid for the first 17 weeks you are off work due to disability. If you qualify for short-term disability payments, then you cannot also receive EI Sickness benefits.
3.3 Long-term Disability Benefits
Long-term disability benefits are disability benefits paid through a disability benefits plan or policy. To qualify for long-term disability benefits, you must be on a prolonged absence from work due to illness or disability. The required absence period, known as the waiting period, typically lasts for 17 weeks but can be longer depending on your disability plan. If you have long-term disability benefits coverage, the waiting period will match the benefit period for EI Sickness or Short-term disability benefits. Long-term disability benefits are paid for a defined period of time, which could be a set number of years or to age 65.
3.4 Canada Pension Plan (CPP) Disability Benefits
If you have worked for 4 of the past 6 years, and paid payroll taxes, then you are probably eligible to apply for CPP disability benefits. If you qualify for CPP disability, you receive a monthly payment until age 65, after which the payment converts to the CPP retirement pension. To qualify you must have a severe and prolonged disability as defined by the CPP disability laws. A severe disability is one that prevents you from performing any work on a regular basis. A prolonged disability is one that is permanent and not expected to improve.
To learn more visit our page on the Canada Pension Plan (CPP) disability program
4. HOW TO APPLY FOR DISABILITY BENEFITS FOR FIBROMYALGIA
Whether you are applying for EI sickness benefits, short-term disability or long-term disability benefits, or CPP disability benefits, each program has a three step process you must follow:
- You get the application package from the disability benefits
- You fill out the required forms and submit them to the plan administrator
- The plan administrator reviews your application then approves or denies your claim
Below we will discuss the process of applying for each type of disability benefit in more detail.
When applying for EI sickness benefits, you will need to fill out an application form online, get a medical certificate from your doctor and a Record of Employment (ROE) from your employer. The ROE must indicate that you are absent from work due to an illness or disability.
When applying for short or long-term disability benefits, you will need to arrange for three forms to be filled out: the Notice of Claim Form, the Employer or Plan Sponsor Statement, and the Attending Physician Form.
You fill out the Notice of Claim Form, make sure you fill out all parts of this form and give detailed answers. If there isn’t enough room on the form, you can attach another page.
Your employer fills out the Employer or Plan Sponsor Form. This form confirms key details about your job duties and salary information. Your employer may fill out this form and send it directly to the insurance company. You should get a copy of the employer’s form to verify that the information on it is correct, it is common for employers’ reports to have errors, both intentional and unintentional.
Your doctor will need to fill out the Attending Physician’s Statement Form. This is the most important form. Your claim will be approved or denied based on the medical report form. You should make an appointment with you doctor for the purpose of filling out this form. Ideally, you want to get a copy of the completed doctor’s form before your doctor sends it to the disability benefits plan administrator.
When applying for CPP disability benefits, you will need to arrange for four forms to be filled out: The Application Form, The Questionnaire, The Medical Report Form and the Child Rearing Provision Form.
You fill out the Application Form and Questionnaire. Make sure you fill out these forms with as much detail as possible. They don’t give much space for each answer, so we recommend you attach additional pages if needed for you to give thorough responses.
Your doctor fills out the Medical Report Form, this is the most important form in this application. With all disability programs, your claim will be approved or denied based on the medical evidence. There is a fee for this form to be filled out by your doctor, but Service Canada will normally reimburse your physician directly.
You fill out the Child Rearing Provision Form, this form is fairly straightforward you just answer the questions honestly, and if you have children born after 1958, you may qualify for a higher benefit amount.
5. MAINTAINING disability payments ONCE YOUR CLAIM IS APPROVED
It is important to understand that even after approval, insurance companies and disability benefits providers continue to review your claim going forward. In other words, you have an obligation to satisfy the disability benefits provider that you remain continuously disabled. In a practical sense, this means the insurance company will request ongoing medical reports from your doctor, will want to get verbal updates from you by phone, and may require you to attend medical assessments and treatment. The frequency and requirements for ongoing proof of our claim will vary depending on the type of disability benefits you are getting.
5.1 EI Sickness Payments for Fibromyalgia
EI sickness payments are the easiest situation. If you are approved for EI sickness benefits, you will get payments for the entire 15 week period as long as your doctor certifies you are unable to work. There is nothing you need to do beyond making sure your doctor’s certificate says you will be off work for the entire 15-week period.
5.2 short- or long-term disability payments for fibromyalgia
If you are approved for short- or long-term disability benefits, the insurance company will continue to review your claim. In the beginning, you can expect the insurance company to review you claim on a bi-weekly or monthly basis. You will need to continue to provide medical updates and information requested by the insurance company. You should cooperate with the insurance company to the best of your ability. The frequency of follow up by the insurance company may decrease if your claim is approved beyond two years from the date you originally stopped work.
5.3 You need cooperate with medical assessments and treatment directed by insurance company
In disability claims involving fibromyalgia, it is common for the insurance company to want you to attend medical assessments, vocational assessments and rehabilitation programs. These assessments and programs are designed to return you to your own employment or to identify alternative work you could do, given your medical condition and limitations. It is also usual for some insurance companies to take the view that your disability is not caused by fibromyalgia and is really just untreated or poorly managed depression. In such cases, they may send you to see a psychiatrist. Such programs and assessments are a source of stress an anxiety. It is common for you and your doctor to disagree with the professionals doing the assessments and rehabilitation program. You should cooperate with the assessments and programs even if you disagree with them.
5.4 Your insurance company may require you to apply for CPP disability benefits
If you have received long-term disability benefits for a year or more, then it is likely the insurance company will require you to apply for CPP disability benefits. Most disability insurance plans and policies have a clause that, in a roundabout way, requires you to apply for CPP disability benefits: you don’t have to apply, but if you don’t, the insurance company has the right to estimate and deduct the amount of the potential CPP disability benefit. They can make this deduction even if you haven’t applied for or received the CPP disability benefit. Most insurers will not estimate and deduct the CPP benefit as long as you are pursing a claim for CPP disability benefits.
6. HOW TO APPEAL A DISABILITY CLAIM Denial FOR FIBROMYALGIA
Even if the insurance company approves your claim for long-term disability benefits for fibromyalgia, there is a high likelihood they will stop your payments at some point within the first two years. Most long-term disability insurance policies will pay disability benefits for two years if fibromyalgia prevents you from do your “own” occupation. After two years disability, you will only qualify for disability benefits if fibromyalgia prevents you from doing “any” occupation.
A common scenario in fibromyalgia claims is that the insurance company will approve you for two years under the “own” occupation clause, but then decline your claim once you get to the “any” occupation requirement. Once you approach the two year deadline, the insurance company will acknowledge that you can’t do your own job, but will then assert that you must be able to do some other job. By the two-year deadline, it will be likely that the insurance company will have paid for assessments or medical opinions that support their view that you can do some other work. The insurance company will choose to rely on their own medical opinions over the objections of your doctor or health professionals.
You have the right to appeal any denial decision by the insurance company. There are several rounds of appeal. So if your first appeal is denied, then you can keep appealing to the next level. The first appeals are called internal appeals and are done directly with the insurance company. If these appeals are denied, then move on to an external appeal. External appeals are done with a decision-maker who is not employed by the insurance company. External appeals involve an appeal hearing or lawsuit against the insurance company.
7. CHALLENGES OF WINNING LONG-TERM DISABILITY BENEFITS FOR FIBROMYALGIA
As we have stated before, disability claim managers will not automatically approve you for disability payments because you have fibromyalgia. A fibromyalgia diagnosis does not mean you are disabled. Fibromyalgia exists on a spectrum of symptoms and disability. Most people living with fibromyalgia are able to work by managing their symptoms or by seeking accommodations at work. It is only when you have exhausted all options, including both medical options and options to work with accommodations, that you will have a chance of winning disability benefits for fibromyalgia.
Below, we review the key challenges that you must first overcome to be successful:
7.1 Most people with fibromyalgia are able to work
Most people with fibromyalgia are able to work. Your challenge is to prove that you are part of the small group of people living with fibromyalgia who are legitimately disabled from work. This is no easy task. The best way to prove you are unable to work is to demonstrate that you have struggled for years to remain in the workforce and have finally reached the breaking point. You will need to show that you have done things like asking for workplace accommodations, attempted reducing your hours, tried removing difficult job duties, even changing your work environment or set-up and changing jobs when necessary. You will also need to show that you have tried every recommended medical treatment or test available.
7.2 The insurance company will get medical reports and assessments that say you can work
No matter how supportive your doctors are, you can be certain the insurance company will find doctors that disagree with them. Sometimes the insurance company’s doctors will examine you and other times they will just review your medical records and give “behind the scenes” opinions to the insurance company. If the insurance company’s doctors say you can work, don’t give up. Your case is not over just because the insurance company has paid for medical reports that support a denial of benefits. You can overcome these negative medical reports by taking a careful approach during your appeals. You need to carefully control the narrative of your disability and appeal.
7.3 There will BE little or no “objective” proof of your disability
Fibromyalgia is an invisible illness. This means that your symptoms and disability cannot be quantified by objective tests like blood work, x-rays or visual observations. From the outside, you will not look disabled. Your disability results from fatigue and chronic pain. There are no tests to measure a person's level of pain or fatigue. Your subjective reports of pain and fatigue are the only way for others to know the seriousness of your symptoms. Doctors often arrive at a diagnosis of fibromyalgia after ruling out other possible explanations for your symptoms. Therefore, it is important that you cooperate with all blood tests and assessments recommended by your doctor. You will need to focus your appeals strategy on proving disability for an invisible illness, and overcoming the natural bias others will have to disbelieve you. This is no easy task but not impossible.
7.4 There will be surveillance appearing to show you doing daily activities without problems
If your claim is approved and you are less than 60 years old, then there is a high probability that the insurance company will have you under video and online surveillance at some point. Because a picture is worth a thousand words, you can expect the insurance company to try and get a video of you doing daily activities. They will try to attack your credibility by getting a video of you doing activities that you have said you can't do, or being more active than you said you are. They will pick apart your every word, so it is critical that you be extremely precise in how you describe your activities, limitations and symptoms. For fibromyalgia, your disability and symptoms are not all or nothing. You will have good and bad days. It is critical that you describe your activities, symptoms and disability in terms of ranges — from good to bad, rather than saying you can or can't do certain things. This is an area where many people go wrong with disastrous results, even if you are well-meaning and legitimately disabled.
For example, we had a legitimately disabled client who told the insurance company that she could "never leave the house anymore". She did not mean this in the literal sense, but the insurance company treated this as a literal statement and got a video of her leaving the house. It didn't matter that she was stuck at home for nine days and went out only on one day. They terminated her disability claim based on insurance fraud. We were able to win her case, but not before a long fight and a very uphill battle, which was totally unnecessary if she had been more precise with her language.
8. Case Studies
Below, we feature case studies of actual cases we have handled so you can see how we apply this Guide into practice. To protect the privacy and confidentiality of our clients, we have changed the names and details in the case studies; however, these are all based on real cases, steps taken and results:
“Whoever tells the best story wins.” - John Quincy Adam
Winning disability benefits for fibromyalgia is not easy. A fibromyalgia diagnosis is not enough to guarantee a claim approval. Having a supportive doctor is not enough. Actually being disabled from work is not enough. So, what does it take?
Winning disability benefits for fibromyalgia is not based on the truth of your situation; rather, it is based on how well your past actions and medical documents demonstrate the truth. The entire strategy for your disability claim and appeals needs to focus on demonstrating your credibility and likability in the eyes of the insurance company and others. Your credibility and likability are the keys to telling a powerful story.
Your success in winning disability benefits for fibromyalgia boils down to whether the story you tell is more convincing than the insurance company’s alternative story about you. Most people, because of conscious and unconscious biases, are inclined to believe the stories told by the insurance company — that you are lazy, you want to retire early, you just don't like your job, you didn't really try, or you are resisting treatment that would make you better. When people have an unconscious bias, they tend to look for information that confirms what they already believe. This is called confirmation bias and it is your biggest enemy. The insurance company, the judge and others will be inclined to believe facts that support negative stereotypes, and will be inclined to ignore facts that go against the stereotypes.
It is human nature that we judge others based on their actions, and we judge ourselves based on our intentions. This is a distinction that many people ignore to their own peril. What do your actions say about you? Do they fit with the negative stereotypes advanced by the insurance company? That you are lazy and haven’t really tried to get better or to stay at work? Or will your actions show just the opposite? That you have tried every possible thing to stay in the workforce. That you have cooperated with all possible treatment in the hope of getting better? Sometimes it can feel like you are jumping through hoops to prove something you think should be obvious. Just remember: what is obvious to you isn’t obvious to everyone else. Your good intentions don't matter — you are being judged by your actions (or inaction).
Still Feeling Unsure About Your Disability Claim or Appeal? Sometimes a quick call with us can answer your concerns and help you move forward with confidence. Call us now at 888-732-0470 for a free consultation.